A common complaint associated with the prostate gland is benign prostatic hyperplasia, or an enlarging of the prostate, resulting in constriction of the urethra and consequent difficulty in urinating. Existing techniques for treating this condition include trans-urethral resectioning of the prostate (TURP for short), a procedure in which an instrument inserted along the urethra of the patient is used to remove the prostate tissue which obstructs the urethra. Typically this procedure is performed using an electrosurgical instrument which resects the prostate tissue, and involves removing the obstructing tissue in a series of thin strips. A disadvantage of this procedure is the consequent removal of virtually all of the urethra in the region of the prostate.
In our U.S. Pat. 6,015,406 which relates inter alia to electrosurgical instruments and their operation for the purpose of debulking, cutting or coagulating tissue, we disclose the use of an electrosurgical instrument having a short, rigid brush electrode to debulk a tumour such as a prostate adenoma. Specifically, we disclose that prostatic adenoma can be treated by drilling a series of holes into the adenoma. The residual tissue bridges will shrink as part of the healing process. Whilst not removing the whole tumour, this technique is safer and quicker than removing the entire adenoma, when treatment is being performed for bladder outflow obstruction, and in addition results in significantly less destruction of the urethra.
The present invention provides a surgical technique for treating bladder outflow obstruction for example, and in one aspect of the present invention access is gained to the treatment site via the bladder itself, as a result of one or more suprapubic conduits.
According to a first aspect of the present invention, there is provided a method of treating prostatic adenoma comprising the steps of:
inserting at least a first conduit suprapubically into the bladder;
inserting at least a surgical instrument along the first conduit;
distending the bladder with an isotonic fluid;
viewing the position of the instrument using at least one of: (a) remote visualisation means, (b) direct visualisation means and (c) a combination of remote and direct visualisation means; and
using the surgical instrument to create at least one hole in the prostate gland, thereby to debulk the adenoma.
This technique has the advantage of leaving the urethra and the bladder neck, while the bladder outflow obstruction is alleviated as the tissue within the prostate gland lying adjacent the urethra collapses into the cavities created by the procedure.
Preferably the procedure is performed using electrosurgery, which offers significant advantages in terms of minimally invasive surgery and patient recovery times in comparison to more conventional forms of surgery. One preferred form of electrosurgery is bipolar electrosurgery in which a conductive path between a pair of electrodes located on an electrosurgical instrument is completed by means of a conductive fluid, such as isotonic saline.
Preferably, a second conduit will be inserted suprapubically into the bladder from a site remote to the insertion of the first conduit, and direct visualisation means in the form of an endoscope will be inserted along the second conduit to enable triangulation of the instrument and the visualisation means, this enabling an improved visualisation of the procedure by the surgeon. The electrically conductive fluid will preferably be supplied to the treatment site via one of the conduits. Exhaust of waste products may also be provided via one of the conduits if desired.
In a preferred embodiment of the method, a preoperative image will be obtained using remote visualisation means, such as transrectal ultrasound, in order to obtain an image which may be used to assess the overall shape of the prostate, and to plan the approximate volume of tissue to be removed by drilling. Such remote visualisation means may also be used during the procedure to assess the depth of tissue drilling relative to structures such as the external sphincter which are preferably preserved.